Physician Trial Form

To be signed by doctor
A clinical procedure is being preformed with a demo C Scope tablet that does not automatically prevent scope reuse. The single-use scope kit items must be discarded once the procedure is complete.
To be signed by sales rep
The C Scope handpiece has been reprocessed with Caviwipes according to the user manual and all patient information gathered during the trial procedure has been deleted from the C Scope tablet.

Thank you! Your form has been submitted.

This information/document is confidential and proprietary. It may not be reproduced, used or disclosed to others without written consent of CIT Ortho. ZSC-200-08-08-20 Rev. 01